CNA's Needed!

Visiting Angels strives to provide the highest quality care to senior citizens. Before filing out your application, I would welcome you to evaluate whether or not you meet Visiting Angels hiring requirements. Per SC State DHEC in home care licensure, all caregivers are required to present the following:

2 Step TB within the past 12 months indicating that you do not have active TB.

Residency documents – DHEC requires that we confirm your state residency. We will need to ask for documentation to support you being a SC resident or another state.

Clean Background with no convictions of theft, drugs, abuse or exploitation of a child or vulnerable adult

If you can pass all of these criteria and if you are truly ready to help change people’s lives by providing loving and compassionate care to those in need, we welcome you to continue on to fill out the questionnaire. If not, we would ask that when you can meet this criteria that you please return and check with us at that time.

Criminal Background - Have you ever been convicted of a misdemeanor or felony? (any omissions or falsifications are subject to termination or application rejection):

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Yes

No

Do you have a driver's license?

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Yes

No

Driver's License State:

Driver's License Expires:

Do you have a car?

Yes

No

Car Make and Model:

Do you auto insurance on your vehicle?

Yes

No

Auto Insurance Company:

Have you had any accidents or moving violations in the pasy 3 years?

Please check all areas you would like to work:

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North Greenville

Central Greenville County

Southern Greenville County

Pickens County

Anderson County

Spartanburg County

May we contact your current employer(s)?

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Yes

No

Your Current Employer OR Last Company You Worked With:

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Current Employer - Phone Number:

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Current Employer - Job Title:

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Current Employer - Start Date:

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Current Employer - End Date:

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Current Employer - Job Duties:

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Current Employer - Direct Supervisor's Name:

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Current Employer - Starting Pay:

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Current Employer - Ending Pay:

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Current Employer - Detailed Reason for Leaving:

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Previous Employer 1 - Company Name:

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Previous Employer 1 - Phone Number:

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Previous Company 1 - Job Title:

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Previous Company 1 - Start Date:

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Previous Company 1 - End Date:

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Previous Company 1 - Job Duties:

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Previous Company 1 - Direct Supervisor's Name:

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Previous Company 1 - Starting Pay:

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Previous Company 1 - Ending Pay:

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Previous Company 1 - Detailed Reason For Leaving:

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Previous Company 2 - Company Name:

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Previous Company 2 - Phone Number:

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Previous Company 2 - Job Title:

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Previous Company 2 - Start Date:

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Previous Company 2 - End Date:

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Previous Company 2 - Job Duties:

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Previous Company 2 - Direct Supervisor's Name:

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Previous Company 2 - Starting Pay:

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Previous Company 2 - Ending Pay:

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Previous Company 2 - Detailed Reason for Leaving:

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Previous Company 3 - Company Name:

Previous Company 3 - Phone Number:

Previous Company 3 - Job Title:

Previous Company 3 - Start Date:

Previous Company 3 - End Date:

Previous Company 3 - Job Duties:

Previous Company 3 - Direct Supervisor's Name:

Previous Company 3 - Starting Pay:

Previous Company 3 - Ending Pay:

Previous Company 3 - Detailed Reason For Leaving:

What Is Your Work Availability:

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Are you available for 12 hour shifts?

Yes

No

Are you available in an emergency?

Yes

No

What is your desired hourly wage? (Please do not state negotiable - we would like an idea of the amount per hour):

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Want Full Time or Part Time?

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Full time

Part time

What is the last year of education completed?

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

College - Year 1

College - Year 2

Associates Degree

College - Year 3

College - Year 4

Bachelors Degree

Masters Degree

PHD

What High School Did You Attend?

High School - City and State:

High School - Years Attended:

1

2

3

4

5

High School - Did you graduate?

Yes

No

What College Did You Attend?

College - City and State:

College - Years Attended:

1

2

3

4

5

6

7

8

College - Did You Graduate?

Yes

No

Are you a CNA that is CURRENTLY certified?

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Yes

No

CNA Certified - In What State?

AK

AL

AR

AZ

CA

CO

CT

DC

DE

FL

GA

HI

IA

ID

IL

IN

KS

KY

LA

MA

MD

ME

MI

MN

MO

MS

MT

NC

ND

NE

NH

NJ

NM

NV

NY

OH

OK

OR

PA

RI

SC

SD

TN

TX

UT

VA

VT

WA

WI

WV

WY

CNA Certificate Number:

Please List Any Other Certifications:

Do you have a current TB?

Yes

No

Do you have a copy of your TB test results?

Yes

No

Do you have a current HBV (Hep. B) series?

Yes

No

Do you have a copy of your HBV (Hep. B) series?

Yes

No

Please select if you have experience with the following:

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Wheelchair Transfers

Bed to commode transfers

Ambulation Assistance

Bathing: Bed/Shower/Tub

Dressing an impaired patient

Feeding an impaired patient

Light Housekeeping

Physical Therapy Exercises

Transporting a client in a car

Meal Preparation

Medication Reminders

Pet Care

Bed Bound - total care

Terminally Ill - Hospice

Stroke with Side Effects

Alzheimer's / Dementia

Urinary / Bowel Incontinence - Brief Changes

Parkinson's Disease

Cancer

Diabetes

Paralysis

Personality Disorders

Gait Belt

Hoyer Lift / Other Lifts

Do you have any other advanced training?

Personal Reference 1 - Name:

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Personal Reference 1 - Number of years you've known him/her:

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Personal Reference 1 - Relationship:

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Personal Reference 1 - Telephone Number:

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Personal Reference 2 - Name:

Personal Reference 2 - How many years have you known him/her?

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Personal Reference 2 - Relationship:

Personal Reference 2 - Telephone Number:

Personal Reference 3 - Name:

Personal Reference 3 - How many years have you known him/her?

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Personal Reference 3 - Telephone Number:

What was your Previous Address?

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Previous Address 1 - How long did you live there?

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Previous Address 2:

Previous Address 2 - How long did you live there?

Previous Address 3:

Previous Address 3 - How long did you live there?

Restrictive Covenant:

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Yes

No

Please click yes if you agree with the following. I agree not to do business directly or indirectly with any individual or business entity that Visiting Angels has introduced me to or by entering into employment with such individuals or entities.

Certification and Release:

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Yes

No

I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions or misrepresentation of facts will result in rejection of this application and/or discharge at any time during employment. I authorize Visiting Angels or ANY third party provider to Visiting Angels to verify any and all information contained within this application for the purposes of obtaining a job with Visiting Angels or at any time thereafter, including but not limited to, reference checks, criminal history and motor vehicle driving records and understand that all application fees to Visiting Angels are non-refundable.